PATIENTS

I have cared for thousands of children and have diagnosed some of them within seconds. I relied on the story of the illness more often than on lab tests or x-rays. A mother may offer the critical facts that determine treatment. The short entries here show that sometimes I am the one that needs treatment and at others the community does.

He’s a Smith!

Hearing Aid

Scrotum

Dermatologist

Abortion

HE’S A SMITH!

It is 1986 and I am the pediatrician on call for my group. The hospital nursery notifies me that a woman is not making progress in her labor. The obstetrician says she will need a Caesarian Section. At Cooley Dickinson Hospital, a pediatrician attends each Caesarian Section to provide any emergency assistance needed by the baby. I drive over to the hospital, go to the delivery suite and gown up. The woman hasn’t made any progress for the past 20 minutes and is prepped for the section.

Not much for me to do. I check my equipment: the laryngoscope and the endotracheal tube that I would use if the baby needed help to start breathing. Then I just wait for the baby to appear. He does and the obstetrician hands him to me. First I score him with respect to color, heart rate, breathing, muscle tone, and startle. Pediatricians check these five points to assess the condition of a newborn baby. They then decide what level of attention the baby requires. This system was developed by Virginia Apgar, my professor at Columbia University in the 1950s.

I check the baby’s heart and lungs, feel the belly and look into his eyes and ears. Everything is O.K. Then I check the hands and feet. I notice that he has a small extra finger next to his fifth finger on each hand. He is healthy, but what should I say to the mother? I want to be honest, but I don’t want to upset her. I give the baby to her without saying anything. She takes one look at him and shrieks, HE’S A SMITH!She was born with extra fingers too.

HEARING AID

I have been wearing a hearing aid for just over three years. Hearing aids are tough, a lot more difficult to adjust to than my bifocals. Thebifocals took a long time because the optician kept putting the line in the wrong place. Anyway, this is about hearing aids. I have trouble understanding my daughter. She has mumbled since she was a teenager. However, conversations at the dinner table became more difficult because I lose a lot of my wife’s words. I cannot hear well while driving, and have trouble following social discussions. In fact, I sometimes cannot understand my patients. I realize that if I spend energy trying to hear, I will not be able to put the usual amount of energy into other observations.

So, time for a hearing evaluation. Soundproof room, one ear, both ears, say words back. Audiologist understands what amplification I need. What else? What type hearing aid? I’m not a vain person, but I did not want anyone to see my hearing aid while I was being interviewed on television. A hearing aid means that you are old and mortal.

“Okay,” says the hearing aid person, “I will give you an ITE (in the ear) type, like President Reagan has. Do you want the special secret on and off switch to keep in your pocket? No one knows when you are tuning them out. It costs an extra two hundred dollars.”

“Not today. I’ll just take the plain Reagan,” I said.

Six weeks later, I have the ITE hearing aid fitted. I turn it on and hear better. Great. A few weeks later, I’m unhappy. The hearing aid itches my ear. I want to pull it out after a couple of hours of use. “Okay,” says the hearing aid person, “Let’s try the clear plastic one that the TV anchors and astronauts wear.” Time passes and I often clean the wax out of the plastic tube. But last week when I took it apart, I can’t get it to stay together. Another trip to the hearing aid person. He says hearing aid tubes are like some people. When they get old, they become brittle, shrunken and fall apart. He gives me a new tube.

SCROTUM

I am in my office working pretty steadily. It is about 4 p.m. when a mother brings in five-year-old Johnny. She is worried because his scrotum is swollen. He takes off his pants, and then his underpants. I look carefully. His scrotum is a little larger than normal for a boy his age. Then I feel. I want to judge the size and consistency of his testicles. They are both normal. When I squeeze them lightly, he does not wince. This is good.

There are several possibilities here. The testicle hangs on a pedicle made up of an artery, vein, and spermatic cord. Sometimes it twists, cutting off the blood supply. This causes severe pain and requires immediate surgical repair. If the testicle stays twisted it will die. Since Johnny has no pain, this is not his problem. Another possibility is mumps, which may cause the testicles to swell and become tender. Johnny’s testicles are normal.

I direct my attention to Johnny’s scrotum. I look carefully at the rugae, or deep creases in his scrotal skin. They are shallow at the base, and the skin has a fullness which makes his scrotum look enlarged. What could do this? Trauma. If Johnny had fallen from his bike and struck his scrotum on the horizontal bar, that could cause the swelling. But Johnny did not ride his bike today.

I tell his Mom, “Johnny’s testicles are okay. The swelling of his scrotum is probably due to some kind of trauma, and I know you will figure out the cause in the next day or two.” The next day she calls to tell me that Johnny was playing in the playground after school two days ago and slid down a pole several times. “Aha! When he slid down the pole, I’ll bet his scrotum wedged against the pole, and was traumatized by the friction as he slid down.” I told her the swelling would be gone in a couple of days.

That night after supper I think, “I am excited. I am making a contribution to medical science.” Every doctor knows about Charcot’s joints, Bechet’s granuloma, Vincent’s angina, and Heberden’s nodes. Well, I am writing a letter to the editor of the New England Journal of Medicine describing a new syndrome, pole slider’s scrotum. I hope that a few years from now, doctors who see a patient like Johnny will recognize this problem and refer to it as Plaut’s scrotum.

THE DERMATOLOGIST

Two weeks after my eightieth birthday I have an appointment with the dermatologist. His receptionist tells me her name is Erika. “That’s my Mom’s name, but you don’t look like her.” She asks me for my insurance cards. I didn’t bring them. I tell her I have moved and give her my new address. Then I sit in the waiting room. It is appropriately named. Then Judy, the assistant, calls me into room number five. Says I can sit in a chair, which I do. She asks, “Do you have allergies?”

“What is the problem, how long have you had it?”

The doctor comes and asks, ”What is the problem?”

“Bumps,” I say. “A lot of bumps on my head.”

He stands close, puts his nose one inch from my head and says, “You do have bumps, about a hundred of them.”

“What causes these bumps?” I ask.

“They are caused by the sun and called actinic dermatitis.”

“I can freeze the big ones,” he says, “but not all of them”

“I don’t think I want them frozen,” I say.

“Well I can give you a salve to burn them off. You would smear it all over your scalp. You do this twice a day for a month and those bumps will be gone. But your head will be red during that time.”

“What happens if I don’t do anything?”

“There is a one to two percent chance that a cancer will develop.”

“What kind, the good or the bad?”

“The bad kind, that can spread and kill you. But if you notice one of your bumps getting bigger and bleeding, just call me and I’ll take care of it.” And, he says, “It might be a good idea to wear a hat in the sun. Oh, forget it. You are too old.”

ABORTION IN NEW YORK STATE

I had been involved in the struggle for abortion rights for years. In the 1960s a friend travelled to Puerto Rico for an abortion. It was a traumatic experience. As a physician, I was concerned that women were dying after having illegal abortions. On April 9,1970 the New York State Assembly voted to legalize abortion by a vote of 76 to 74. My Assemblyman was part of the one vote majority. The state Senate and the governor followed suit, making New York the first state in the nation to legalize abortion. Within months about 20 abortion clinics sprang up in New York City.

No official body had the power to evaluate these facilities. To make sure that abortions would be safe I joined with five other physician directors of the of the progressive Physicians’ Forum to assess the clinics. We offered to evaluate each one, and to list those that met our standards in a brochure. Because the clinics wanted to attract referrals and patients, they were happy to have us visit.

We established the following criteria for listing:

A twenty-four hour hotline to handle emergencies

No extra charge for Rhogam

A good safety record

Accurate accounting of complications

A clean facility

Rhogam prevents an O-negative woman who is carrying an O-positive fetus from developing antibodies. Without it a subsequent pregnancy could result in permanent damage or death of the fetus. The cost of the abortion was about $100 and the Rhogam was an additional $100. We knew that many women who needed it wouldn’t be able to afford the Rhogam. We insisted that $25 be added to the fee for every abortion. This extra charge would allow every woman who needed Rhogam to get it.

Each of us visited several facilities. I checked three clinics on the East Side of New York City. The first one was located on the second floor of an apartment building on 110th Street. Planned Parent chapters from other states referred clients there. Six frightened young women were sitting in the waiting room when I entered. The clinic director welcomed me and showed me the procedure room. There wasn’t much to see, just two simple beds separated by a white curtain. We went to an anteroom where I asked several questions.

“How many abortions have you done in the past six months?”

“Ten a day, that would make 60 a week or 1500 in six months.”

“And how many complications?”

“None.”

“That’s a surprise since every type of surgery causes complications.”

“Do you include a charge for Rhogam in your fee for every patient?”

“No we charge $100 when it is needed.”

“Do all O negative women receive Rhogam?”

“Only if they can pay.”

“Do you have a 24-hour hotline that patients can call in case of emergency?”

“What is a hotline?”

I explained and he responded, “Well, no, we don’t.”

This visit had not been a good experience for me. I walked down the stairs to the parking lot behind the clinic. A minute later the director followed me down. He said he now remembered that he once had had a complication, a perforated uterus. And he asked, “What would it take (meaning how much would it cost) to list my clinic in the brochure?”

“It’s free if you qualify, I said.” We did not list him.

The directors of the two other clinics I assessed gave satisfactory answers to my questions. We listed them in the brochure that we distributed to physicians. Our first print run was 10,000 copies. Our group of volunteer physicians thought we had done our job. We had inspected and rated about twenty clinics in New York City and then made our findings available to physicians and the public.

At the same time, foes of abortion attacked the new law and the legislators who had voted for it. In 1972 they introduced a bill to repeal the law. Its sponsors wanted to stop legal abortions. Of course, this would put women’s lives at risk. We had worked hard to make abortions safe, but we knew that there was more work to do. I was affiliated with two of the many groups that would travel to the state capital in Albany to urge our legislators to defeat repeal of the law.

I decided to go to Albany. In preparation, I called my legislator, Vince Russo (not his real name), to find out where he stood on the issue. He didn’t commit himself but invited me to ride to Albany with him. A few months earlier, Johanna and I had hosted a fundraiser to support his re-election campaign. Vince picked me up. The chief lobbyist for the New York City firefighters union was behind the wheel. I almost died of fright as we sped up the Taconic Parkway at 90 miles an hour.

I am sitting in the back seat. Vince turns and says,

“Your people want me to vote against repeal, don’t they?”

“No, Vince, we don’t. We understand that a large part of your district is Catholic. You would have a hard time getting re-elected if you voted against repeal.”

“Then what do you want me to do?”

“Just have an accident.”

“What do you mean?”

“Well, just wind up in the hospital on the day of the vote.”

The Catholic Church lobbied fiercely for the bill that would make abortion illegal again. No one knew how it would fare. The night before the vote I learned that Vince had been hospitalized with a serious kidney problem. We still have a chance, I thought. I was wrong. The next day, May 9,1972, repeal won by a vote of 79 to 68. Fortunately, Governor Nelson Rockefeller vetoed it. Eight months later the United States Supreme Court handed down Roe v. Wade and legalized abortion nationally.

I did not save abortion in New York State, but worked hard to protect the women who needed it.